Heart Attack Patients Do Best at Hospitals That Specialize

Across America, hospitals large and small have been racing to offer angioplasty and other minimally invasive treatments to open blocked heart arteries. But not all of them have the ability to do it on an emergency basis, performing angioplasty around the clock on heart attack patients. So, during evenings and weekends, many hospitals use clot-busting drugs instead.

Now, a national study based on data from 37,233 patients casts a shadow on this practice of "part-time" emergency angioplasty.

In the Jan. 17 Circulation, a team led by University of Michigan and Yale University cardiologists reports that patients are less likely to die during their hospital stay, and will receive faster treatment, if they have their emergency angioplasty at hospitals where it is the "default" treatment, used on the vast majority of heart attack patients.

By contrast, the in-hospital death risk and risk of delayed treatment were both higher for angioplasty patients treated at hospitals where emergency angioplasty was used in a minority of heart-attack patients. On the whole, they were significantly more likely to die before leaving the hospital, and waited an average of 20 minutes longer for treatment, than those treated at hospitals where most heart attack patients received angioplasty. Many waited far longer than the 90 minute "window" during which emergency angioplasty is thought to have an edge over clot-busting drugs.

Surprisingly, the study also suggests that hospitals' level of "specialization" in emergency angioplasty has more to do with patient survival than the sheer number of emergency angioplasties performed there each year. Previous studies have shown that patients do better when they receive angioplasties and other such treatments at hospitals where many such procedures take place each year.

"In the case of emergency angioplasty, for hospitals it seems that it's not just how many you do, but how used to doing them you are," says lead author Brahmajee Nallamothu, M.D., MPH, an assistant professor of internal medicine at the U-M Medical School, researcher at the VA Ann Arbor Healthcare System and member of the U-M Cardiovascular Center. "The overall commitment to doing emergency angioplasties, and the protocols and staffing that come out of that commitment, appear to be key." The bottom line for anyone having a heart attack, he adds, is still to call 911 and let the emergency medical staff decide which hospital to choose.

The study was funded by a National Heart, Lung and Blood Institute grant led by Harlan Krumholz, M.D., a professor at Yale University School of Medicine, and used data from the National Registry of Myocardial Infarction collected from 2000 to 2002.

"This study has direct policy implications for hospitals trying to decide what services to provide," says Krumholz. "It seems best to decide on a single approach to the care of patients with heart attacks and stick to it."